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Bat bite?
THE LANCET 3
Shoffner J, Wallace D. “Oxidative phosphorylation diseases”. In: Scriver C, Beaudet A, Sly W, Valle D, eds. The metabolic and molecular bases of inherited disease. 7th ed. New York: McGrawHill, 1535–629: 1995.
Division of Medical Genetics, Childrens Hospital Los Angeles, CA 90027, USA (R G Boles); Departments of Pediatrics and Pathology, University of Southern California School of Medicine, Los Angeles; and Department of Pediatrics, Stanford University School of Medicine, Stanford
reaction. As far as we are aware, this is the first report of amiodarone causing this potentially severe complication. 1
Harjai KJ, Licata AA. Effects of amiodarone on thyroid function. Ann Intern Med 1997; 126: 63–73.
Internal Medicine Unit, Hospital Casa Maternitat, Corporació Sanitària Clínic, 08036 Barcelona, Spain (X Bosch)
Acute pancreatitis during treatment with amiodarone
Bat bite?
Xavier Bosch, Oscar Bernadich
A 37-year-old woman was in her bathroom and felt something brush against her bottom. When she turned on the lights, there was a bat hanging on the ceiling. The bat escaped through the open bathroom window. She looked at her skin and found nothing unusual, but she called her physician for reassurance. Her physician insisted that she be examined. Later that day, she saw her physician. No evidence of trauma was seen where the contact had occurred; however, her physician scrutinised the area with an otoscope (6⫻ magnification), and found two pinpoint punctures approximately one-half centimeter apart. It was thought that these puncture marks could have been from the bat’s teeth but it was later considered more likely that they were from the bat’s claws. She was given post-exposure rabies prophylaxis and has remained well. The figure shows the mouth and right claw of a silver-haired bat. These bats weigh but a few ounces and their claws and teeth are very sharp. In 1995, a 4-year-old girl from the state of Washington, USA, and a 13-year-old girl from Connecticut, USA, died of rabies. In both cases, a bat was present in the children’s houses but no contact was recognised. Since 1980, there have been 28 cases of human rabies acquired in the United States, 15 were caused by rabies-virus strains associated with bats (ten were the virus strain typically isolated from the silver-haired bat). Most of these 15 patients never reported a bat bite or scratch. Because a bat scratch or bite may be very small and may not be felt, it is now recommended that “in situations in which a bat is physically present and the person(s) cannot reasonably exclude the possibility of a bite exposure, post-exposure prophylaxis should be given unless prompt capture and testing of the bat has excluded rabies virus infection”.1
Amiodarone is useful to treat ventricular arrhythmia, paroxysmal supraventricular tachycardia, and atrial fibrillation and flutter. Furthermore, its use after myocardial infarction may reduce complex ventricular ectopics and cardiac-related mortality. However, the efficacy of amiodarone in improving survival after myocardial infarction and in patients with heart failure has been questioned.1 We report a 46-year-old woman who developed acute pancreatitis while on amiodarone. She had been well until 1 month before admission (June, 1996) when digoxin 0·25 mg per day was prescribed for atrial fibrillation secondary to newly diagnosed rheumatic mitral stenosis. 8 days before admission, digoxin was stopped because of severe gastric intolerance (anorexia, persistent nausea, and some diarrhoea) despite serum concentrations within the normal range. Amiodarone was given instead as an oral loading dose of 800 mg daily for 1 week, then 400 mg daily for the next 3 weeks, and then a maintenance dose of 200 mg or less per day. Symptoms of digoxin intolerance disappeared spontaneously within 2 days of stopping digoxin and starting amiodarone. After 4 days of amiodarone (ie, 4 days before admission), she developed nausea, vomiting, and constant pain in the epigastrium that radiated to the flanks, which became progressively worse until admission. Amiodarone had not been discontinued at any time before admission. She denied any alcohol or other drug use. Physical examination was remarkable for moderate abdominal tenderness with absent bowel sounds; in addition, cardiac auscultation revealed an irregularly irregular rhythm, an opening snap, and a III/IV decrescendo diastolic rumble at the apex. Laboratory data showed leucocytosis (16⫻109/L) with a normal differential count and increased serum pancreatic isoamylase (1480 U/mL; normal 17–115) and lipase (946 U/mL; normal 0–190). Serological tests for mycoplasma, viral hepatitis, and other viral infections were negative. Abdominal ultrasonography was normal but the pancreas could not be seen due to excess bowel gas. On computerised tomography, the pancreas was apparently normal. Amiodarone was discontinued and procainamide (sustained release form) 3000 mg per day given instead. 5 days after admission, serum pancreatic isoamylase and lipase values returned to normal and the patient was symptom-free. 8 days after admission, procainamide was stopped and amiodarone 100 mg per day reinstituted with the patient’s informed consent and under intensive clinical surveillance. 3 days later, amiodarone had to be discontinued because of new clinical and biological evidence of pancreatic injury (nausea, vomiting, abdominal pain, isoamylase 662 U/mL, lipase 446 U/mL). The patient’s serum pancreatic profile returned to normal 3 days later. Procainamide was restarted and pancreatitis has not recurred 12 months after admission. The temporal relation and recurrence on reexposure are highly suggestive of amiodarone-induced acute pancreatitis, which seemed not to be related to cumulative dose or duration of therapy but was probably an idiosyncratic-type
1300
Henry M Feder Jr, Randall Nelson, Herbert W Reiher
1
Human rabies—Connecticut. MMWR 1996; 45: 207–09.
Department of Family Medicine, University of Connecticut Health Center and Connecticut Children’s Medical Center, CT 06030-1406, USA (H M Feder Jr); Connecticut State Department of Health, Hartford, Connecticut; and Private Practice Internal Medicine, South Windsor, Connecticut
Silver-haired bat Scale is in cm.
Vol 350 • November 1, 1997
Shoffner J, Wallace D. “Oxidative phosphorylation diseases”. In: Scriver C, Beaudet A, Sly W, Valle D, eds. The metabolic and molecular bases of inherited disease. 7th ed. New York: McGrawHill, 1535–629: 1995.
Division of Medical Genetics, Childrens Hospital Los Angeles, CA 90027, USA (R G Boles); Departments of Pediatrics and Pathology, University of Southern California School of Medicine, Los Angeles; and Department of Pediatrics, Stanford University School of Medicine, Stanford
reaction. As far as we are aware, this is the first report of amiodarone causing this potentially severe complication. 1
Harjai KJ, Licata AA. Effects of amiodarone on thyroid function. Ann Intern Med 1997; 126: 63–73.
Internal Medicine Unit, Hospital Casa Maternitat, Corporació Sanitària Clínic, 08036 Barcelona, Spain (X Bosch)
Acute pancreatitis during treatment with amiodarone
Bat bite?
Xavier Bosch, Oscar Bernadich
A 37-year-old woman was in her bathroom and felt something brush against her bottom. When she turned on the lights, there was a bat hanging on the ceiling. The bat escaped through the open bathroom window. She looked at her skin and found nothing unusual, but she called her physician for reassurance. Her physician insisted that she be examined. Later that day, she saw her physician. No evidence of trauma was seen where the contact had occurred; however, her physician scrutinised the area with an otoscope (6⫻ magnification), and found two pinpoint punctures approximately one-half centimeter apart. It was thought that these puncture marks could have been from the bat’s teeth but it was later considered more likely that they were from the bat’s claws. She was given post-exposure rabies prophylaxis and has remained well. The figure shows the mouth and right claw of a silver-haired bat. These bats weigh but a few ounces and their claws and teeth are very sharp. In 1995, a 4-year-old girl from the state of Washington, USA, and a 13-year-old girl from Connecticut, USA, died of rabies. In both cases, a bat was present in the children’s houses but no contact was recognised. Since 1980, there have been 28 cases of human rabies acquired in the United States, 15 were caused by rabies-virus strains associated with bats (ten were the virus strain typically isolated from the silver-haired bat). Most of these 15 patients never reported a bat bite or scratch. Because a bat scratch or bite may be very small and may not be felt, it is now recommended that “in situations in which a bat is physically present and the person(s) cannot reasonably exclude the possibility of a bite exposure, post-exposure prophylaxis should be given unless prompt capture and testing of the bat has excluded rabies virus infection”.1
Amiodarone is useful to treat ventricular arrhythmia, paroxysmal supraventricular tachycardia, and atrial fibrillation and flutter. Furthermore, its use after myocardial infarction may reduce complex ventricular ectopics and cardiac-related mortality. However, the efficacy of amiodarone in improving survival after myocardial infarction and in patients with heart failure has been questioned.1 We report a 46-year-old woman who developed acute pancreatitis while on amiodarone. She had been well until 1 month before admission (June, 1996) when digoxin 0·25 mg per day was prescribed for atrial fibrillation secondary to newly diagnosed rheumatic mitral stenosis. 8 days before admission, digoxin was stopped because of severe gastric intolerance (anorexia, persistent nausea, and some diarrhoea) despite serum concentrations within the normal range. Amiodarone was given instead as an oral loading dose of 800 mg daily for 1 week, then 400 mg daily for the next 3 weeks, and then a maintenance dose of 200 mg or less per day. Symptoms of digoxin intolerance disappeared spontaneously within 2 days of stopping digoxin and starting amiodarone. After 4 days of amiodarone (ie, 4 days before admission), she developed nausea, vomiting, and constant pain in the epigastrium that radiated to the flanks, which became progressively worse until admission. Amiodarone had not been discontinued at any time before admission. She denied any alcohol or other drug use. Physical examination was remarkable for moderate abdominal tenderness with absent bowel sounds; in addition, cardiac auscultation revealed an irregularly irregular rhythm, an opening snap, and a III/IV decrescendo diastolic rumble at the apex. Laboratory data showed leucocytosis (16⫻109/L) with a normal differential count and increased serum pancreatic isoamylase (1480 U/mL; normal 17–115) and lipase (946 U/mL; normal 0–190). Serological tests for mycoplasma, viral hepatitis, and other viral infections were negative. Abdominal ultrasonography was normal but the pancreas could not be seen due to excess bowel gas. On computerised tomography, the pancreas was apparently normal. Amiodarone was discontinued and procainamide (sustained release form) 3000 mg per day given instead. 5 days after admission, serum pancreatic isoamylase and lipase values returned to normal and the patient was symptom-free. 8 days after admission, procainamide was stopped and amiodarone 100 mg per day reinstituted with the patient’s informed consent and under intensive clinical surveillance. 3 days later, amiodarone had to be discontinued because of new clinical and biological evidence of pancreatic injury (nausea, vomiting, abdominal pain, isoamylase 662 U/mL, lipase 446 U/mL). The patient’s serum pancreatic profile returned to normal 3 days later. Procainamide was restarted and pancreatitis has not recurred 12 months after admission. The temporal relation and recurrence on reexposure are highly suggestive of amiodarone-induced acute pancreatitis, which seemed not to be related to cumulative dose or duration of therapy but was probably an idiosyncratic-type
1300
Henry M Feder Jr, Randall Nelson, Herbert W Reiher
1
Human rabies—Connecticut. MMWR 1996; 45: 207–09.
Department of Family Medicine, University of Connecticut Health Center and Connecticut Children’s Medical Center, CT 06030-1406, USA (H M Feder Jr); Connecticut State Department of Health, Hartford, Connecticut; and Private Practice Internal Medicine, South Windsor, Connecticut
Silver-haired bat Scale is in cm.
Vol 350 • November 1, 1997